- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $300.44 / $300.44 / $982.00
| Facility | | $300.44 | $300.44 | $982.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $285.02 / $300.44 / $308.04
| Professional | | $285.02 | $300.44 | $308.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,366.20 / $1,612.11 / $2,519.40
| Professional | | $1,366.20 | $1,612.11 | $2,519.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,010.50 / $13,010.50 / $16,052.30
| Facility | | $13,010.50 | $13,010.50 | $16,052.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.00 / $50.00 / $60.00
| Professional | | $40.00 | $50.00 | $60.00 |